Molecules to Medicine: When Religion Collides with Medical Care: Who Decides What Is Right for You?by Jay

The recent presidential candidate debates, fights over insurance coverage for contraceptives, and the Virginia and Texas legislatures’ imposition of intrusive, unnecessary ultrasounds prior to any abortions are highlighting the fundamental issue of the role of religion in health care and the separation of Church and State. While the emphasis has been on reproductive care, the imposition of religious beliefs on access to medical care is far more wide reaching in its deleterious effect on the ability of people to choose their care and have their medical needs met.

Since I first started medical school, two principles were inculcated in me as foundations of medicine. First was the importance of searching for—and following—evidence in medicine, and the large human cost of not doing so. Second was our promise to the public, via the Hippocratic oath and centuries of precedent, to put patients’ needs first, above our own. I’ve dedicated my professional life to these tenets.

I hope to share some historical background on the intersection between medical care and religion, and what happens when we deviate from these central tenets of patient-centric care and then, in a subsequent post, tell more about the impacts of religious beliefs on research and public health.

As you read, consider: “When religion collides with your medical care, who should decide what is right for you?”

Background:

Access to health care information, health services and medical research has being limited by two growing trends: the infusion of increasingly restrictive religious doctrines at faith-based health systems and the implementation of ideologically-driven, rather than scientific, evidence-based, public policies.

Many hospitals with religious sponsors (Presbyterian, Methodist, Episcopalian and Jewish) are functionally secular and do not limit patient choices based on theology. In contrast, religious doctrine dictates what services will (or will not) be provided at some Baptist hospitals and all Adventist and Catholic health care institutions (HCIs). Religious restrictions affect not only reproductive care, which has garnered the bulk of attention, but affects access to new technologies, end-of-life care choices, vaccination, risk reduction counseling, and even access to scientific information.

Ideologically driven policies impact our ability to care for our patients using evidence-based medicine and have wide-ranging repercussions. As an Infectious Diseases physician and clinical researcher, I’ll share some of the impacts I have witnessed, including those from the bitter merger between the Catholic hospital and secular hospital in my own rural community. (Disclosure: I opposed the merger, from the heretical belief that health care decisions should be between a patient and his or her physician, and not dictated by anyone else’s religious beliefs.)

Physician and community impact

On local levels, religiously based restrictions can interfere with access to care and physician privileges, the approval to practice in a specific health care institution. Physicians must apply for and be granted such “privileges” to practice at each hospital. Catholic-affiliated institutions require that any physician requesting privileges agree, in writing, to abide by the Ethical and Religious Directives as a condition of practice; s/he will not be granted privileges, or may have those privileges revoked if s/he violates the ERDs, even in the interest of saving a patient’s life.

Nearly one-third of all Catholic hospitals are located in rural areas. In many cases, the Catholic health system becomes the sole provider of care in a county or entire region. This particularly impacts rural patients, who may be unable to seek health care in larger metropolitan areas, hours away. Depending on the nature of the medical problem, the weather and road conditions, the state of public transportation, and lack of money/support, it is often not practical or feasible for a patient to seek healthcare elsewhere.

In general, stricter interpretations of religious doctrine are being applied to a variety of issues. The general public and health care consumers are often unaware of these restrictions until confronted with a problem, as negotiations are often conducted behind closed doors. This was true in my own community, where all negotiating parties—even the mayor—were under a gag order not to reveal details of a proposed merger.

Following are some of the less publicized aspects of the impact of religion on access to health care.

Last summer, the Institute of Medicine recommended that women receive full coverage of contraceptives as part of essential preventive care for them, stating, “To reduce the rate of unintended pregnancies, which accounted for almost half of pregnancies in the U.S. in 2001, the report urges that HHS consider adding the full range of Food and Drug Administration-approved contraceptive methods as well as patient education and counseling for all women with reproductive capacity.

Women with unintended pregnancies are more likely to receive delayed or no prenatal care and to smoke, consume alcohol, be depressed, and experience domestic violence during pregnancy. Unintended pregnancy also increases the risk of babies being born preterm or at a low birth weight, both of which raise their chances of health and developmental problems.”

Similarly, some state legislatures have become more conservative, eroding what have been broad standards of medical care and patients’ rights to access to care. One suchstates’ rights trend also uses so-called “conscience clauses,” which are being used not only to exempt individuals from participating in acts that they personally find morally objectionable, but increasingly to allow organizations, including hospitals and insurers, to exempt themselves from providing services, counseling, or referral.

For example, legislation passed in Mississippi gives health providers, institutions, payers, and potential employees the absolute right to refuse to participate in (including providing services, counseling, or referring patients for) any health service to which they have a moral objection. There are no exceptions to protect a patient’s health or life.

At Louisiana State University Medical Center, a young woman with cardiomyopathy was denied a medically necessary abortion, forcing her to be transferred to Texas to save her life. And in 2010, in Phoenix, Sr. Margaret McBride was excommunicated for allowing an abortion to save the life of a critically ill 27-year old mother of four. There is a pattern of religious mandates that endanger a woman’s life by requiring that “physicians act contrary to the current standard of care.”

Arizona’s Senate has just passed a bill that shields physicians from litigation for failing to inform pregnant women of prenatal problems or lying to their patients if the truth could lead to the decision to seek an abortion. Texas has just sacrificed cancer screening and preventive care for poor women because some of those funds go to Planned Parenthood—even though the funds are not used for abortion. This is guilt by association, as the law will cut off clinics with any affiliation to a provider, no matter how tangential.

Similar bills are pending in several other states and in Congress. The American Bar Association responded, passing a resolution opposing “governmental actions and policies that interfere with patients’ abilities to receive from their healthcare providers … all of the relevant and medically accurate information necessary for fully informed healthcare decision making. . .as defined by the applicable medical standard of care, whether or not the provider chooses to offer such care.”

Although they may be cloaked innocently, as “conscience” clauses, this belies their nature. They are, instead, unconscionable clauses, allowing health care workers to shirk the professional responsibility to put their patients first. Refusal clauses deny our patients the care that they need. They should be publicly identified and bluntly referred to as such—a refusal to provide care.

End of Life issues

Religious restrictions affect far more than contraception and abortion.

Many organizations have appealed to the JCAHO to require health care entities that have institutional ethical or religious restrictions concerning certain health care services and information to provide explicit and timely written notice of those restrictions to prospective patients and staff. (After the merger in our community, services were shifted between the secular and Catholic hospitals.

My elderly mother had to be hospitalized at the Catholic hospital to receive necessary services (or travel a considerable distance). No one in registration, admitting, the operating room, or her floor could tell us what the policy “Living wills will be honored if not in conflict with hospital policy” meant, adding considerable needless stress to an already difficult situation. This was also in violation of the Patient Self-Determination Act (PSDA), which requires institutions receiving Medicare or Medicaid funding to provide notification as to whether a patient’s Advanced Directive will be honored.

If religious organizations want to impose their beliefs on others who do not share them, should they be receiving public monies—our monies—to deny care that we need and deserve? Should their “conscience” trump yours? Who should decide what care is right for you?